Unauthorized Drugs and Neglected Care Lead to Patient’s Severe Decline At Integrity Healthcare of Carbondale

The Illinois Department of Health has cited and fined Integrity Healthcare of Carbondale when a resident developed 15 new wounds and severe oral deterioration after staff continued administering medications that doctors had specifically ordered to be discontinued. The unauthorized medications caused extreme drowsiness, leading to the resident’s decline and eventual hospitalization for sepsis.

The resident in question was initially hospitalized for pneumonia, and when discharged back to the facility, the hospital specifically ordered two medications (Haldol and Clonazepam) to be discontinued. However, the facility continued giving these medications without a physician’s order, which caused the resident to become very drowsy and stop eating and drinking properly.

The situation was particularly serious because when the resident returned to the facility, staff failed to properly assess his skin condition, implement proper treatments, or notify doctors about new pressure ulcers that were developing. A nursing assistant
later discovered concerning skin issues, including dark red areas on the resident’s tailbone and heels, but despite reporting these findings, proper medical assessment and treatment weren’t provided.

The severity of the neglect is captured in this quote from a hospital nurse who later treated the resident: “Patient has over 15 new wounds since last admission, he received Haldol and benzos in the nursing home which were discontinued by our team at the time of the discharge, patient became somnolent due to this and stopped eating and was readmitted this time.”

The neglect extended to basic oral care as well. When the resident was readmitted to the hospital, his mouth was in poor condition. As one hospital nurse described it, the resident’s mouth “looked like the bottom of the Sahara desert.” The resident’s tongue was covered in a dry, scaly, cracking coating with fissures and thick yellow/brown residue.

A hospital physician later stated that the continued administration of the discontinued medications caused drowsiness, which led to the resident not eating or drinking properly. The physician also noted that the facility’s failure to turn and reposition the resident led to the development of multiple pressure ulcers, and the lack of oral care for approximately 5-6 days caused severe build-up on the resident’s tongue.

The resident’s family member had ongoing concerns about the care, noting that every time they visited, the resident’s lips were dry and chapped, and the resident was always thirsty.

The facility’s administrator acknowledged these failures, expressing disappointment particularly about the condition of the resident’s mouth.

This case highlights a series of serious care failures including medication errors, lack of skin care, and inadequate oral care, all of which contributed to the resident’s decline and suffering.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.